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ItemInvestigating current evidence and practices for improving the nutritional status and outcomes of patients undergoing resection for upper gastrointestinal cancer( 2022)Upper gastrointestinal (UGI) cancers, including oesophageal, gastric, and pancreatic tumours, are amongst cancers with the lowest survival rates worldwide. The usual curative treatment option for these cancers is major resection, often combined with preoperative (neoadjuvant) oncological therapy. Although advances in surgical techniques have led to improved clinical outcomes, surgery for UGI cancer is still considered a highly morbid and major procedure. Malnutrition affects up to 80% of patients with UGI cancer and is associated with poor outcomes, including decreased oncological treatment tolerance and functional capacity, and increased hospital length of stay (LOS), complications, and mortality. Provision of perioperative nutrition support for UGI cancer sufferers is therefore highly recommended in current surgical and oncology evidence-based guidelines. However, there are no evidence-based nutritional practice guidelines specifically for patients with UGI undergoing neoadjuvant therapy and surgery. In the preoperative setting, most evidence for nutrition support is derived from studies of mixed gastrointestinal cancer populations or patients undergoing definitive chemoradiotherapy. Thus, the optimal nutrition support methods for patients prior to UGI cancer resection are largely unclear. Although many studies have assessed the nutritional status of patients with UGI cancer, few have been conducted at the time of surgery using validated assessment methods. Furthermore, little is known about the current perioperative dietetics and nutritional interventions patients receive in the clinical setting, and their association with surgical outcomes. Multidisciplinary management of nutrition is recommended in patients with cancer, but the perspectives of multidisciplinary clinicians – including dietitians, surgeons, oncologists, and nurses – remain under-researched. This thesis presents a program of research which included four distinct but related studies that addresses the lack of knowledge about current UGI surgical oncology nutrition research. Study 1 was a national point prevalence study of 200 patients undergoing UGI cancer resection; the largest study internationally to assess nutritional status in a cohort of oesophageal, gastric, and pancreatic cancer surgery using validated assessment methods. This study indicated that malnutrition and weight loss are highly prevalent in current UGI surgical oncology populations, and factors associated with these conditions were identified. However, provision of dietetics and nutrition support in both the preoperative and postoperative settings were varied and inadequate, leading to increased LOS and complications. Study 2, a national survey of multidisciplinary clinicians, found that they were aware of the significance of malnutrition and the importance of nutrition support, but key barriers to provision of optimal nutrition support must be overcome in the clinical setting. More barriers were identified in the outpatient than in the inpatient setting, including lack of funding for dietitians, variation in practices, and a lack of standardized procedures or pathways. Study 3 was a systematic review of the current evidence for nutrition support in the neoadjuvant and preoperative setting. It found that overall, there is a lack of strong evidence about optimal methods of nutrition support prior to UGI cancer surgery. Study 4 was a multisite pilot study of the implementation of a standardized perioperative nutrition care pathway. Analysis showed that its implementation increased access to preoperative nutrition care, but also indicated a complex clinical and implementation environment requiring consideration in future practice and research studies. This program of research provides detailed and novel data about practices for, and evidence about, improving the nutritional status and outcomes of patients undergoing resection for UGI cancer. The data presented in this thesis will enable the development of robust clinical trials, leading to the establishment of specific evidence-based nutrition guidelines.